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\begin{document}

\title{Posterior reversible encephalopathy syndrome and spinal extradural
hematoma in an elderly patient}



\author[1]{Kouhei Onishi}%
\author[1]{Susumu Uchida}%
\author[1]{Hirotaka Fudaba}%
\author[1]{Yukari Kawasaki}%
\author[1]{Masaki Morishige}%
\author[1]{Minoru Fujiki}%
\affil[1]{Oita University}%


\vspace{-1em}



  
  \date{June 03, 2024}


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\begin{abstract}
Posterior reversible encephalopathy syndrome (PRES) is identified on
magnetic resonance imaging by posterior predominant white and gray
matter lesions. PRES secondary to spinal disease is very rare. We report
a case of clinical and imaging findings about PRES associated with
spinal epidural hematoma.%
\end{abstract}%



\sloppy


\textbf{Posterior reversible encephalopathy syndrome and spinal epidural
hematoma}

\textbf{in an elderly patient}

\textbf{Kouhei Onishi, Susumu Uchida, Hirotaka Fudaba, Yukari Kawasaki,}

\textbf{Masaki Morishige, Minoru Fujiki}

Department of Neurosurgery, Graduate School of Medicine, Oita
University, Oita, Japan

\textbf{Corresponding Author:} Kouhei Onishi

Department of Neurosurgery, School of Medicine, Oita University

1-1, Idaigaoka, Hasama-machi, Yufu, Oita 879-5593, Japan

TEL: +81-97-586-5861, FAX: +81-97-586-5869, E-mail:
k-onishi@oita-u.ac.jp

\emph{Key Clinical Massage}

Various factors, such as persistent hypertension and renal failure
caused onset of posterior reversible encephalopathy syndrome triggered
by spinal epidural hematoma. We must pay attention to risk factors of
PRES even in spinal disease.

\emph{Keywords}

Posterior reversible encephalopathy syndrome, spine, epidural hematoma

\emph{Introduction}

Posterior reversible encephalopathy syndrome (PRES) is identified on
magnetic resonance (MR) imaging by posterior predominant white and gray
matter lesions. The common clinical features are headache, seizures, and
visual loss, often in the setting of renal failure, accelerated
hypertension and following administration of immunosuppressive drugs. It
is widely accepted that the mechanism of PRES is the generation of
vasogenic edema caused by failure of cerebral autoregulation and the
production of cytotoxic edema due to ischemia. PRES secondary to spinal
disease is very rare. Only a few reports show PRES occurred in patients
with spinal epidural hematoma. Here, we report a case of clinical and
imaging findings about PRES associated with spinal epidural hematoma.

\emph{Case history}

A 81-year-old woman suddenly presented with intense neck pain and
developed rapidly progressive quadriparesis. She had previously been
diagnosed with hypertension and chronic renal failure. Neurological
examination showed severe right-sided dominant tetraplegia. Sensory
deficit was difficult to exam because of her confusion.

\emph{Investigation and Treatment}

On admission to the emergency hospital, her blood pressure was
152/82mmHg and pulse was 60/min. She had mild delirium. Routine blood
analysis showed renal function tests were raised (blood urea nitrogen
28.0mg/dl and serum creatinine 2.11mg/dl). Serum electrolytes ware
normal.

Brain MR imaging showed left occipital white matter and left cerebellum
slight hyperintensities on fluid-attenuated inversion recovery
(FLAIR)-sequences (Fig.1 a). MR imaging of the spine showed a large
epidural hematoma compressing the dorsolateral surface of spinal cord at
the levels C2-Th4 (Fig.1 c-d) and intramedullary hematoma at C4/5 (Fig.1
e). No abnormally enlarged vessels were observed on T2 weighted image.

Next day, on admission to our hospital, she was still confused, and her
clinical findings were not improved. Brain and spinal MR performed,
spinal epidural hematoma was not decreased and white matter of right
temporooccipital lobes and cerebellum FLAIR high lesions were revealed
clearly (Fig.1 b). She underwent a C3-T1 hemi-laminectomy and removal of
epidural hematoma.

\emph{Outcome and Follow-up}

On the postoperative stage, she complained of delirium, partial seizure,
persistent hypertension, and worsen renal failure. Use of
antihypertensive \& anticonvulsant medication and undergoing temporary
hemodialysis (Fig.4).

Post operative MR spine demonstrate that epidural hematoma was removed
but spinal edema still remained (Fig.3 c-e). Brain MR done 17days after
surgery showed complete reversibility of the hyper-intense lesions on
FLAIR (Fig.3 b).

Her general status was improved gradually and no more seizures were
observed. Her arms and legs weakness remained and she kept on aggressive
physiotherapy. Her neurological findings were improved gradually and she
changed hospital to undergo rehabilitation. 4 months later, she could
walk without assistance.

\emph{Discussion}

PRES was first described in 1996 and is a well-known syndrome that
typically presents with a headache, seizures and visual disturbance
{[}1{]}. The most common cause of PRES is sever hypertension, renal
failure, immunosuppressant therapy, chemo therapy, eclampsia and
autoimmune disorder. In connection with spinal disease, though several
reports show PRES associated with autonomic dysreflexia in spinal cord
injury patients {[}2-4{]}, only a few reports with spinal epidural
hematoma. PRES due to spinal epidural hematoma has occurred such rarity
with 2 cases reported previously {[}5, 6{]} (Table1). Among them, only 2
cases caused by spontaneous spinal epidural hematoma including our case.
Case No.2 is postoperative case. Spontaneous spinal epidural hematoma
itself could not lead to PRES, so several risk factors are connected.

\emph{Conclusion}

We report a case of PRES due to acute spinal epidural hematoma. In our
case, various factors including persistent hypertension, renal failure
caused onset of PRES triggered by spinal epidural hematoma. We must pay
attention to risk factors of PRES even in spinal disease.

\emph{Acknowledgments}

No relevant acknowledgments.

\emph{Conflict of Interest Statement}

The authors declare that there was no conflict of interest regarding the
publication of this paper.

\emph{Author contribution}

Kouhei Onishi: drafted the manuscript and contributed to treatment of
the patient.

Susumu Uchida: drafted the manuscript and contributed to treatment of
the patient.

Hirotaka Fudaba: contributed to treatment of the patient and
participated in critical review and in the revision of the manuscript.

Yukari Kawasaki: participated in critical review and in the revision of
the manuscript.

Masaki Morishige: participated in critical review and in the revision of
the manuscript.

Minoru Fujiki: participated in critical review and in the revision of
the manuscript.

All authors have read and approved the final manuscript.

\emph{References}

1. Hinchey J, Chaves C, Appignani B. 1996. A reversible posterior
leukoencephalopathy syndrome. N Engll J Med. 334:494-500

2. CJ Chaves. 2008. Reversible posterior leukoencepalopathy in a patient
with autonomic dysreflexia: a case report. Spinal Cord 46: 760-761.

3. Yamashita T. 2012. Cerebral Hemorrhage Due to Posterior Reversible
Encephalopathy Syndrome Associated With Autonomic Dysreflexia in a
Spinal Cord Injury Patient. Neurol Med Chir 52: 640-643.

4. Farooq S. 2017. Acute visual loss in a patient with spinal cord
injury. Spinal Cord Ser Cases 3: 17080

5. P Striano. 2007. Posterior reversible encephalopathy syndrome and
spinal epidural hematoma in a hypertensive patient. European Journal of
Anaeshesiology 24: 1057-1069.

6. Chittur VG. 2011. Posterior Rversible Encephalopathy Syndrome in a
Case of Postoperative Spinal Extradural Hematoma: Case Report and Review
of Literature. Asian Spine Jurnal 5: 64-67.\selectlanguage{english}
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